Local Coverage Determination (LCD)

Home Health Physical Therapy

L34564

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Proposed LCD
Proposed LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed LCDs are not necessarily a reflection of the current policies or practices of the contractor.

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L34564
Original ICD-9 LCD ID
Not Applicable
LCD Title
Home Health Physical Therapy
Proposed LCD in Comment Period
N/A
Source Proposed LCD
N/A
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 05/23/2024
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
N/A
Notice Period End Date
N/A

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Issue

Issue Description

This LCD outlines limited coverage for this service with specific details under Coverage Indications, Limitations and/or Medical Necessity.

Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

Title XVIII of the Social Security Act, §1814(a)(2)(C) addresses the requirement of requests and certifications.

Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, §1862(a)(7) excludes routine physical examinations.

42 CFR §409.42 Beneficiary qualifications for coverage of services

42 CFR §409.43 Plan of care requirements

42 CFR §409.44 Skilled services requirements

42 CFR §410.61 Plan of treatment requirements for outpatient rehabilitation services

42 CFR §424.22 Requirements for home health services

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7, §30.4 Needs Skilled Nursing Care on an Intermittent Basis (Other than Solely Venipuncture for the Purposes of Obtaining a Blood Sample), Physical Therapy, Speech-Language Pathology Services, or Has Continued Need for Occupational Therapy, §30.5 Physician or Allowed Practitioner Certification and Recertification of Patient Eligibility for Medicare Home Health Services, §30.5.1.1 Face-to-Face Encounter, §40 Covered Services Under a Qualifying Home Health Plan of Care, §40.2 Skilled Therapy Services, §40.2.1 General Principles Governing Reasonable and Necessary Physical Therapy, Speech-Language Pathology Services, and Occupational Therapy and §40.2.2 Application of the Principles to Physical Therapy Services

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §220 Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services) Under Medical Insurance, §220.2 Reasonable and Necessary Outpatient Rehabilitation Therapy Services, §220.3 Documentation Requirements for Therapy Services, §230 Practice of Physical Therapy, Occupational Therapy, and Speech-Language Pathology, §230.1 Practice of Physical Therapy, and §230.5 Physical Therapy, Occupational Therapy and Speech-Language Pathology Services Provided Incident to the Services of Physicians and Non-Physician Practitioners (NPP)

CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 1, §30.1 Biofeedback Therapy and §30.1.1 Biofeedback Therapy for the Treatment of Urinary Incontinence

CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 2, §150.5 Diathermy Treatment, §160.7 Electrical Nerve Stimulators, §160.7.1 Assessing Patients Suitability for Electrical Nerve Stimulation Therapy, §160.12 Neuromuscular Electrical Stimulator (NMES), §160.13 Supplies Used in the Delivery of Transcutaneous Electrical Nerve Stimulation (TENS) and Neuromuscular Electrical Stimulation (NMES), §160.15 Electrotherapy for Treatment of Facial Nerve Palsy (Bell’s Palsy) and §160.27 Transcutaneous Electrical Nerve Stimulation (TENS) for Chronic Low Back Pain (CLBP)

CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 3, §170.1 Institutional and Home Care Patient Education Programs

CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, §240.3 Heat Treatment, Including the Use of Diathermy and Ultra-Sound for Pulmonary Conditions, §270.1 Electrical Stimulation (ES) and Electromagnetic Therapy for the Treatment of Wounds and §270.6 Infrared Therapy Devices

CMS Internet-Only Manual, Pub. 100-08, Medicare Program Integrity Manual, Chapter 6, §6.2 Medical Review of Home Health Services, §6.2.1 Physician Certification of Patient Eligibility for the Medicare Home Health Benefit, §6.2.1.1 Certification Requirements, §6.2.2 Physician Recertification, §6.2.2.1 Recertification Elements, §6.2.3 The Use of the Patient’s Medical Record Documentation to Support the Home Health Certification, §6.2.5 Medical Necessity of Services Provided, §6.2.6 Examples of Sufficient Documentation Incorporated Into a Physician’s Medical Record and §6.2.7 Medical Review of Home Health Demand Bills

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Although there is an overlap in services provided by physical and occupational therapists, this policy addresses only physical therapy (PT).

PT services are part of a constellation of rehabilitative services designed to improve or restore physical functioning as well as to prevent injury, impairments, activity limitations, participation restrictions and disability following disease, injury or loss of a body part. Impairments, activity limitations and disabilities are addressed by the examination, evaluation and development of a plan of care that may include implementation of therapeutic interventions tailored to the specific needs of the individual patient to achieve specific goals and outcomes. The specific interventions that may be utilized are therapeutic exercises to strengthen muscles, maintain or restore motion, integumentary repair and protection techniques, physical agents and mechanical modalities such as heat, cold, electrotherapeutic modalities, ultrasound (US) and hydrotherapy, manual therapy and functional training or retraining an individual to perform the activities of daily living.

Rehabilitation Services for Vision Impairment - Partial or complete vision loss may make therapy to improve activities of daily living reasonable and necessary.

Maintenance Therapy

Coverage of skilled rehabilitation services is contingent upon beneficiary’s need for skilled care whether the goals of therapy include maintenance or improvement.
 
Restorative/Rehabilitative Therapy

Restorative/rehabilitative therapy has the purpose of improving function or reversing loss of function.

General Physical Therapy Guidelines

A beneficiary must require the services of a skilled physical therapist for the service to be covered. The pressing need for a service, or the lack of availability of unskilled personnel to render the service with the necessary frequency does not itself make a service skilled. However, some services that would not normally be considered skilled therapy, may require the skilled services of a therapy professional because of a special complicating medical factor. This must be clearly evident in the medical record.  

SPECIFIC PROCEDURE AND MODALITY GUIDELINES:

FABRICATION/APPLICATION OF SPLINTS AND STRAPPING

1. Fabrication and application (as appropriate) of splints and strapping (e.g., the use of elastic wraps, heavy cloth and adhesive tape) are used to enhance performance of tasks or movements, support weak or ineffective joints or muscles, reduce/correct joint limitations/deformities, and/or protect body parts from injury. Splints and strapping are often used in conjunction with therapeutic exercise, functional training, and other interventions and should be selected in the context of a patient’s needs and social/cultural environments.

2. The physical therapist targets the problems in performance of movements or tasks. The physical therapist may select (or fabricate) the most appropriate device or equipment, fit it and train the patient and/or caregiver(s) in its use and application. The goal is for the patient to function at a higher level by decreasing functional limitations.

3. The simple application of a commercial splint or brace will not be considered in this section.

Application long arm splint

May be indicated for the shoulder and/or elbow in the treatment of fractures, dislocations, sprains/strains, tendonitis, post-op reconstruction, contractures or other deformities involving soft tissue.

Application of short arm splint

May be indicated for the forearm, wrist and/or hand in the treatment of fractures, dislocations, sprains/strains, tendonitis, post-op reconstruction, contractures or other deformities involving soft tissue.

Application of finger splint

May be indicated for the finger in the treatment of fractures, dislocations, sprains/strains, tendonitis, post-op reconstruction, contractures or other deformities involving soft tissue.

Strapping of thorax

May be indicated for the thoracic spine, lumbar spine, rib cage or abdominal musculature in the treatment of contusions, fractures, sprains/strains, post-op conditions, neuromuscular conditions, contractures or other deformities involving soft tissue.

Strapping of low back

May be indicated for the lumbar spine, rib cage or abdominal musculature in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuromuscular conditions, contractures or other deformities involving soft tissue.

Strapping of shoulder (e.g., Velpeau)

May be indicated for any portion of the shoulder girdle complex, or rib cage in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuromuscular conditions, contractures or other deformities involving soft tissue.

Strapping of elbow or wrist

May be indicated for the elbow and wrist when there is involvement of the humerus, forearm, wrist or hand in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, contractures or other deformities involving soft tissue.

Strapping of hand or finger

May be indicated when there is involvement of the hand or finger(s) in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuromuscular conditions, edema, scar management, contractures or other deformities involving soft tissues.

Application of long leg splint

May be indicated when there is involvement of the femur, patella, tibia, fibula, ankle or foot in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, contractures or other deformities involving soft tissue.

Application of short leg splint

May be indicated when there is involvement of the tibia, fibula, ankle or foot in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, contractures or other deformities involving soft tissue.

Strapping of hip

May be indicated when there is involvement of the lower back, abdomen or hip in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuromuscular conditions, contractures or other deformities involving soft tissue.

Strapping of knee

May be indicated when there is involvement of the thigh, knee, or lower leg in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuromuscular conditions, contractures or other deformities involving soft tissue.

Strapping of ankle and/or foot

May be indicated when there is involvement of the lower leg, ankle and/or foot in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuromuscular conditions, contractures or other deformities involving soft tissue.

Strapping of toes

May be indicated when there is involvement of any of the toes in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuromuscular conditions, contractures or other deformities involving soft tissue.

Application of Unna boot

A dressing for ulcers resulting from venous insufficiency, consisting of a paste made from gelatin zinc oxide and glycerin which is applied to the leg then covered with a spiral bandage, this in turn being given a coat of the paste. The process is repeated until satisfactory rigidity is attained.

Biofeedback training any method and biofeedback training perineal muscles, anorectal or urethral sphincter

The coverage criteria and definition of biofeedback therapy is found in the CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 1, §30.1 Biofeedback Therapy and §30.1.1 Biofeedback Therapy for the Treatment of Urinary Incontinence.

Biofeedback is a tool utilized by physical therapists to assist with muscle training. This includes facilitation of muscles that are demonstrating suboptimal performance as well as relaxation of muscles that may be inhibiting coordinated movement. Biofeedback can be visual or auditory.

Muscle testing, manual

Muscle testing, manual (separate procedure) with report; extremity (excluding hand) or trunk

For extremity manual muscle testing, every muscle of at least 1 extremity would need to be tested, with documentation of why such a thorough assessment was warranted.

Muscle testing, manual (separate procedure) with report; hand, with or without comparison with normal side

Manual testing of hands only.

Muscle testing, manual (separate procedure) with report; total evaluation of body, excluding hands or including hand

The measurement of muscle performance using manual muscle testing only.

Range of Motion (ROM) Measurements

Determination of ROM using a tape measure, flexible ruler, electronic device or goniometer.

PT Evaluation and PT Re-evaluation

Evaluation is a comprehensive service that requires professional skills to make clinical judgments about conditions for which services are indicated based on objective measurements and subjective evaluations of patient performance and functional abilities. Evaluation is warranted at the start of therapy or when the beneficiary’s condition changes or treatment needs change so as to potentially warrant a new plan of care or a change to an existing plan of care. The time spent in evaluation does not count as treatment time.

1. The initial examination has the following components:

a. The patient history to include prior level of function,

b. Relevant systems review,

c. Tests and measures,

d. Current functional status (abilities and deficits), and

e. Evaluation of patient's, physician's, and as appropriate the caregiver's goals.

2. Factors that influence the complexity of the examination and evaluation process include the clinical findings, extent and duration of loss of function, prior functional level, social/environmental considerations, educational level, the patient's overall physical and cognitive health status, social/cultural supports, psychosocial factors and use of adaptive equipment. Thus, the evaluation reflects the chronicity or severity of the current problem, the possibility of multi-site or multi-system involvement, the presence of preexisting systemic conditions or diseases, and the stability of the condition. Physical therapists also consider the level of the current impairments and the probability of prolonged impairment, functional limitation, the living environment, prior level of function, the social/cultural supports, psychosocial factors, and use of adaptive equipment.

3. Initial evaluations or re-evaluations may be determined reasonable and necessary even when the evaluation determines that skilled rehabilitation is not required if the patient's condition showed a need for an evaluation, or even if the goals established by the plan of treatment are not realized.

4. Re-evaluation is considered reasonable and necessary when the beneficiary’s condition changes or treatment needs change so as to potentially warrant a new plan of care or a change to an existing plan of care. Some regulations and state practice acts require re-evaluation at specific intervals.

5. Re-evaluations are appropriate periodically to assess progress toward goals established in the plan of treatment, or to identify and establish interventions for newly developed impairments at least once every 30 days, for each therapy discipline. 

Maintenance Programs

A maintenance program is a program designed to help a beneficiary maintain an existing level of function or minimize a loss of function. Coverage of skilled rehabilitation services is contingent upon beneficiary’s need for skilled care whether the goals of therapy include maintenance or improvement.

Hot or Cold Packs Therapy

1. Hot or cold packs are used primarily in conjunction with therapeutic procedures to provide analgesia, relieve muscle spasm and reduce inflammation and edema. Typically, cold packs are used for acute, painful conditions, and hot packs for sub-acute or chronic painful conditions.

2. Hot or cold packs applied in the absence of associated procedures or modalities, or used alone to reduce discomfort are considered not reasonable and necessary and therefore, are not covered.

Mechanical Traction Therapy

1. Traction is generally limited to the cervical or lumbar spine with the hope of relieving pain in or originating from those areas.

2. Specific indications for the use of mechanical traction include:

a. Cervical and/or lumbar radiculopathy

b. Back disorders such as disc herniation, lumbago, and sciatica

Vasopneumatic Device Therapy

1. The use of vasopneumatic devices may be considered reasonable and necessary for the application of pressure to an extremity for the purpose of reducing edema.

2. Specific indications for the use of vasopneumatic devices include:

a. Reduction of edema after acute injury

b. Lymphedema of an extremity

c. Education on the use of a lymphedema pump for home use

Note: Further treatment of lymphedema by a physical therapist after the educational visits are generally not reasonable and necessary. Generally, education can be completed in 3 visits.

Paraffin Bath

1. Paraffin bath, also known as hot wax treatment, is primarily used for pain relief in chronic joint problems of the wrists, hands, and feet.

2. Heat treatments alone do not typically make the skills of a therapist reasonable and necessary. However, heat treatments in the presence of a complicating medical factor may make the skills of a therapist reasonable and necessary.

Whirlpool

1. Whirlpool baths do not ordinarily require the skills of a qualified physical therapist. However, in a particular case, the skills, knowledge and judgment of a qualified physical therapist might be required in such treatments or baths (e.g., where the patient's condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fractures or other complications). Also, if such treatments are given prior to but as an integral part of a skilled PT procedure, they would be considered part of the PT service.

Diathermy Treatment

The coverage criteria and definition of diathermy treatment is found in the CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 2, §150.5 Diathermy Treatment and Part 4, §240.3 Heat Treatment, Including the Use of Diathermy and Ultra-Sound for Pulmonary Conditions.

Infrared Therapy

The coverage criteria and definition of infrared therapy is found in the CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, §270.6 Infrared Therapy Devices.

Electrical Stimulation Therapy

Electrical Nerve Stimulation (TENS) is not reasonable and necessary for the treatment of Chronic Low Back Pain (CLBP) under §1862(a)(1)(A) of the Social Security Act.

Electromagnetic Therapy

Electromagnetic therapy criteria and definition are found in the CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, §270.1 Electrical Stimulation (ES) and Electromagnetic Therapy for the Treatment of Wounds.

Contrast Bath Therapy

1. Contrast baths are a special form of therapeutic heat and cold that can be applied to distal extremities. The effectiveness of contrast baths is thought to be due to reflex hyperemia produced by the alternating exposure to heat and cold. Although a variety of applications are possible, contrast baths often are used in treatment to decrease edema and inflammation.

2. The use of contrast baths is considered reasonable and necessary to desensitize patients to pain by reflex hyperemia produced by the alternating exposure to heat and cold.

3. Specific indications for the use of contrast baths include:

a. The patient having rheumatoid arthritis or other inflammatory arthritis

b. The patient having reflex sympathetic dystrophy

c. The patient having a sprain or strain resulting from an acute injury

4. Heat treatments and contrast baths do not ordinarily require the skills of a qualified physical therapist. However, in a particular case, the skills, knowledge and judgment of a qualified physical therapist might be required in such treatments or baths (e.g., where the patient’s condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fractures or other complications). Also, if such treatments are given prior to but as an integral part of a skilled PT procedure, they would be considered part of the PT service.

Ultrasound (US) Therapy 

1. Therapeutic US is a deep heating modality that produces a sound wave of 0.8 to 3.0 MHz. In the human body US has several pronounced effects on biologic tissues. It is attenuated by certain tissues and reflected by bone. Thus, tissues lying immediately next to bone can receive an even greater dosage of US, as much as 30% more. Because of the increased extensibility US produces in tissues of high collagen content, combined with the close proximity of joint capsules, tendons, and ligaments to cortical bone where they receive a more intense irradiation, US therapy is an ideal modality for increasing mobility in those tissues with restricted ROM.

2. The application of US is considered reasonable and necessary for patients requiring deep heat to a specific area for reduction of pain, spasm, and joint stiffness, and the increase of muscle, tendon and ligament flexibility.

3. Specific indications for the use of US application include:

a. The patient having tightened structures limiting joint motion that require an increase in extensibility

b. The patient having symptomatic soft tissue calcification

c. The patient having neuromas

Note: US application is not considered to be reasonable and necessary for the treatment of asthma, bronchitis or any other pulmonary condition.

GENERAL GUIDELINES FOR THERAPEUTIC PROCEDURES:

1. Therapeutic procedures are procedures that attempt to reduce impairments and improve function through the application of clinical skills and/or services.

2. Use of these procedures require that the services be rendered under the supervision of a qualified physical therapist.

3. Therapeutic exercises and neuromuscular re-education are examples of therapeutic interventions. The expected goals documented in the written plan of treatment, effected by the use of each of these procedures, will help define whether these procedures are reasonable and necessary. Therefore, since any 1 or a combination of more than 1 of these procedures may be used in a written plan of treatment, documentation must support the use of each procedure as it relates to a specific therapeutic goal.

4. Services provided concurrently by a physical therapist and occupational therapist may be covered if separate and distinct goals are documented in the treatment plans.

5. Requires (1-on-1) direct patient contact

Therapeutic Exercises

1. Therapeutic exercise is performed with a patient either actively, active-assisted, or passively participating (e.g., treadmill, isokinetic exercise, lumbar stabilization, stretching and strengthening).

2. Therapeutic exercise with an individualized physical conditioning and exercise program using proper breathing techniques can be considered for a patient with activity limitations secondary to cardiopulmonary impairments.

3. Therapeutic exercise is considered reasonable and necessary if at least 1 of the following conditions is present and documented:

a. The patient having weakness, contracture, stiffness secondary to spasm, spasticity, decreased joint ROM, gait problem, balance and/or coordination deficits, abnormal posture, muscle imbalance

b. The patient needing to improve mobility, flexibility, strengthening, coordination, control of extremities, dexterity, ROM, or endurance as part of activities of daily living training, or re-education

4. Documentation for therapeutic exercise typically includes objective loss of joint motion, strength, and/or mobility (e.g., degrees of motion, strength grades, levels of assistance).

Neuromuscular Re-education

1. This therapeutic procedure is provided to improve balance, coordination, kinesthetic sense, posture, and proprioception (e.g., proprioceptive neuromuscular facilitation, BAP’s boards, and desensitization techniques).

2. Neuromuscular re-education may be considered reasonable and necessary for impairments, which affect the body’s neuromuscular system (e.g., poor static or dynamic sitting/standing balance, loss of gross and fine motor coordination, tilt table or standing table, hypo/hypertonicity) and improvement of motor control and motor learning.

Gait Training Therapy

1. This procedure may be reasonable and necessary for training patients whose walking abilities have been impaired by neurological, muscular, or skeletal abnormalities or trauma.

2. Specific indications for gait training include:

a. The patient having suffered a cerebral vascular accident resulting in impairment in the ability to ambulate, now stabilized and ready to begin rehabilitation

b. The patient having recently suffered a musculoskeletal trauma, requiring ambulation re-education

c. The patient having a chronic, progressively debilitating condition for which safe ambulation has recently become a concern

d. The patient having had an injury or condition that requires instruction in the use of a walker, crutches, or cane

e. The patient having been fitted with a brace/lower limb prosthesis and requires instruction in ambulation

f. The patient having a condition that requires retraining in stairs/steps or chair transfer in addition to general ambulation.

Massage Therapy

1. Massage is the application of systemic manipulation to the soft tissues of the body for therapeutic purposes. Although various assistive devices and electrical equipment are available for the purpose of delivering massage, use of the hands is considered the most effective method of application, because palpation can be used as an assessment as well as a treatment tool.

2. Massage therapy, including effleurage, pétrissage, and/or tapotement (stroking, compression, percussion) may be considered reasonable and necessary if at least 1 of the following conditions is present and documented:

a. The patient having paralyzed musculature contributing to impaired circulation

b. The patient having sensitivity of tissues to pressure

c. The patient having tight muscles resulting in shortening and/or spasticity of affected muscles

d. The patient having abnormal adherence of tissue to surrounding tissue

e. The patient requiring relaxation in preparation for neuromuscular re-education or therapeutic exercise

f. The patient having contractures and decreased ROM

3. In most cases, postural drainage and pulmonary exercises can be carried out safely and effectively by nursing personnel. To be considered for payment, the physical therapist must identify the intervention that is best suited for the patient, taking into consideration the patient’s condition and any contraindications that may be present. As there can be an overlap of skills between disciplines, i.e., respiratory therapy, skilled nursing and PT, the documentation must clearly support the need for the intervention to be provided by the physical therapist.

Manual Therapy

1. Joint Mobilization (Peripheral or Spinal)

This procedure may be considered reasonable and necessary if restricted joint motion is present and documented. It may be reasonable and necessary as an adjunct to therapeutic exercises when loss of articular motion and flexibility impedes the therapeutic procedure.

2. Soft Tissue Mobilization

This procedure involves the application of skilled manual therapy techniques (active or passive) to soft tissues in order to effect changes in the soft tissues, articular structures, neural or vascular systems. Examples are facilitation of fluid exchange, restoration of movement in acutely edematous muscles, or stretching of shortened muscular or connective tissue.

Soft tissue mobilization can be considered reasonable and necessary if at least 1 of the following conditions is present and documented:

a. The patient having restricted joint or soft tissue motion in an extremity, neck or trunk

b. Treatment being a necessary adjunct to other physical therapy interventions 

Orthotics Training

1. This procedure may be considered reasonable and necessary if there is an indication for education on the application of the orthotic, the orthotic is in the home and the functional use of the orthotic is documented.

2. Generally, orthotic training can be completed in three visits; however, for modification of the orthotic due to healing of tissues, change in edema, or impairment in skin integrity, additional visits may be required.

3. The medical record should document the distinct treatments rendered when orthotic training for a lower extremity is done during the same visit as gait training or self-care/home management training.

4. The patient is capable of being trained to use the particular device prescribed in an appropriate manner. In some cases, the patient may not be able to perform this function, but a responsible individual can be trained to use the device.

Prosthetic Training

1. This procedure may be considered reasonable and necessary if there is an indication for education on the application of the prosthesis, the prosthesis is in the home and the functional use of the prosthetic is documented.

2. The medical record should document the distinct goals and service rendered when prosthetic training for a lower extremity is done during the same visit as gait training or self-care/home management training.

3. Periodic revisits beyond the third month would require documentation to support medical necessity.

Therapeutic Activities

1. Therapeutic activities are considered reasonable and necessary for patients needing a broad range of rehabilitative techniques that involve movement. Movement activities can be for a specific body part or could involve the entire body. This procedure involves the use of functional activities (e.g., bending, lifting, carrying, reaching, catching, and overhead activities) to improve functional performance in a progressive manner. The activities are usually directed at a loss or restriction of mobility, strength, balance, or coordination. They require the skills of a physical therapist and are designed to address a specific functional need of the patient. These dynamic activities must be part of an active treatment plan and be directed at a specific outcome.

2. In order for therapeutic activities to be covered, the following requirements must be met:

a. The patient having a condition for which therapeutic activities can reasonably be expected to restore or improve functioning

b. The patient’s condition being such that he/she is unable to perform therapeutic activities except under the direct supervision of a physician or physical therapist

c. There being a clear correlation between the type of exercise performed and the patient’s underlying medical condition for which the therapeutic activities were prescribed

Sensory Integrative Techniques

Sensory integrative techniques are interventions generally intended for the pediatric and/or neurologically impaired populations. The focus of these activities is to train the sensory systems to modulate the vast array of incoming sensory stimuli. This is something that is normally performed without apparent effort. Once the patient/client learns to block the extrasensory 'noise', the important sensory input can be processed and a coordinated motor response can be generated.

Self-Care/Home Management Training

The coverage criteria and definition of self-care management training is found in the CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 3, §170.1 Institutional and Home Care Patient Education Programs.

Community/Work Reintegration

PT services that are related solely to specific employment opportunities, work skills, or work settings are not reasonable and necessary for the diagnosis and treatment of an illness or injury and are excluded from coverage by section 1862(a)(1)(A) of the Social Security Act.

Wheelchair Management Training

1. This service trains the patient in functional activities that promote optimal safety, mobility and transfers. Patients who are wheelchair bound may occasionally need skilled input on positioning to avoid pressure points, contractures, and other medical complications.

2. This procedure is reasonable and necessary only when it requires the skills of a qualified physical therapist and is designed to address specific needs of the patient. This training must be part of an active treatment plan directed at a specific goal.

3. The patient and/or caregiver must have the capacity to learn from instructions.

4. Typically 3 to 4 sessions should be sufficient to teach the patient and/or caregiver these skills.

Prosthetic Checkout

1. These assessments are reasonable and necessary for established patients who have already received the orthotic or prosthetic device (permanent or temporary).

2. These assessments may be reasonable and necessary when patients experience a loss of function directly related to the device (e.g., pain, skin breakdown, and falls).

3. These assessments may be reasonable and necessary for determining the patient's response to wearing the device, determining whether the patient is donning/doffing the device correctly, determining the patient's need for padding, underwrap, or socks and determining the patient's tolerance to any dynamic forces being applied.

Physical Performance Test or Measurement

This testing may be reasonable and necessary for patients with neurological or musculoskeletal conditions when such tests are needed to formulate or evaluate a specific treatment plan, or to determine a patient’s functional capacity.

Assistive Technology Assessment

This assessment requires professional skill to gather data by observation and patient inquiry and may include limited objective testing and measurement to make clinical judgments regarding the patient's condition(s). Assessment determines, e.g., changes in the patient's status since the last visit and whether the planned procedure or service should be modified. Based on these assessment data, the professional may make judgment about progress toward goals and/or determine that a more complete evaluation or re-evaluation is indicated.

Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes
Changes Fields Changed
N/A
Associated Information
Sources of Information
Bibliography
Open Meetings
Meeting Date Meeting States Meeting Information
N/A
Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
N/A
MAC Meeting Information URLs
N/A
Proposed LCD Posting Date
Comment Period Start Date
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Coding Information

Bill Type Codes

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Revenue Codes

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CPT/HCPCS Codes

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ICD-10-CM Codes that Support Medical Necessity

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ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

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Group 1 Codes:

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Additional ICD-10 Information

General Information

Associated Information

Documentation Requirements

1. Documentation supporting medical necessity should be legible, relevant and sufficient to justify the services billed. This documentation must be made available to the A/B HHH MAC upon request.

2. The plan of treatment written by the patient’s physician after any needed consultation with the qualified physical therapist and signed and dated by the physician. This must be in the patient’s medical record and made available to the A/B HHH MAC upon request.

3. When documenting family member/caregiver training and education, the documentation should include the person(s) being trained and the effectiveness of the training and education. The training and education should be an adjunct to the active therapy with the patient.

4. Outcome Assessment Information Set (OASIS) data should support the medical necessity of the services documented in the medical records. For therapy services the OASIS MO2200 should be filled out completely and filed with the State Repository. An updated and completed OASIS for the billing period should be on file with the State Repository and in the patient’s medical records to be made available to the A/B HHH MAC upon request.

5.The HH clinical notes must contain documentation elements as outlined in the CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7, §40.2.1 General Principles Governing Reasonable and Necessary Physical Therapy, Speech-Language Pathology Services, and Occupational Therapy.

6. Documentation should justify:

• the individual is under the care of a physician or non-physician practitioner 
• services require the skills of a therapist
• services are of the appropriate type, frequency, intensity and duration for the individual needs of the patient

7. For restorative/rehabilitative therapy documentation should establish:

• variables that influence the patient's condition
• services provided at the time of treatment
• objective measurements that the patient is making progress toward goals

8. In maintenance programs the documentation must reflect that skilled therapy is necessary to achieve the goals of the planned maintenance program.

9. Physician documentation must support coverage.

10Under a restorative program the therapist should adjust the exercise program when needed to meet the beneficiary's needs in response to regular re-evaluation. 

Evaluation/Re-evaluations

Evaluations must contain the referral reason, conditions treated with therapy, and prior level of function, current level of function, and exam findings. Objective measurements must be used to support this information. In addition, planned treatment techniques, limitations, goals, and planned frequency and duration of therapy must also be documented.

Plan of Treatment

Services must be delivered in accordance with a plan of care, which contains the following: diagnosis and problems being addressed planned treatment techniques, measurable functional goals, frequency and duration of service, and rehabilitation potential.

Treatment Note/Clinical Notes/Progress Notes

A treatment note should be written for each visit describing the services performed as well as the patient’s progress, and any treatment variations from the plan of care with an explanation for them. Progress must be documented using specific and objective descriptions (e.g., ROM in degrees, distance that can be walked, validated scales of functional independence). Vague descriptions such as “doing well” or “continue treatment plan,” will not be considered sufficient documentation of the treatment session to justify that the services rendered were reasonable and necessary.

Certification/Re-certification

Certification requirements must be met as per the CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7, §30.5 Physician or Allowed Practitioner Certification and Recertification of Patient Eligibility for Medicare Home Health Services.

Utilization Guidelines

The record must indicate whether the plan is restorative or for maintenance. 

Sources of Information
N/A
Bibliography

A Payer’s Guide to Interventions Provided by Physical Therapists and related CPT® Coding. 2nd Ed. Alexandria, Va: American Physical Therapy Association; 2006.

American Medical Association. CPT® Assistant. December 2003;13(12):6.

American Medical Association. CPT® Assistant. February 2004;14(2):5-6.

American Medical Association. CPT® Assistant. July 2004;14(7):13.

American Medical Association. CPT® Assistant. August 2006;16(8):11.

American Medical Association. CPT® Assistant. February 2007;17(2):8-9,12.

American Medical Association. Coding Consultation. April 2002:18.

Birrer, RB. Sports Medicine for the Primary Care Physician. 2nd ed. Boca Raton:CRC Press;1994.

Delisa JA. Rehabilitation medicine: Principles and practice. The Jour of Hand Surg. 1994;19(4):707.

Guide to Physical Therapist Practice. Phys Ther. 1997;77:1163-1650.

Kottke FJ, Lehmann JF. Krusen’s Handbook of Physical Medicine and Rehabilitation. 4th ed. Philadelphia, Pa: W.B. Saunders Company;1990.

Matsumura BA, Ambrose AF. Balance in the elderly. Clin Geriatr Med. 2006;22(2):395-412.

Studenski SA, Duncan P, Maino JH. Principles of Rehabilitation in Older Patients. In: Hazzard WR, Blass JP, Ettinger WH, Halter JB, Ouslander JG. Principles of Geriatric Medicine and Gerontology. 4th ed. New York, NY: McGraw Hill Companies;1999:Chapter 31.

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
05/23/2024 R24

Under Bibliography removed source: International classification of functioning, disability and health: ICF. Geneva: World Health Organization, 2001, as it is no longer utilized. Formatting, punctuation, and typographical errors were corrected throughout.

  • Provider Education/Guidance
04/27/2023 R23

Under CMS National Coverage Policy added “CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7, §30.5 Physician or Allowed Practitioner Certification and Recertification of Patient Eligibility for Medicare Home Health Services” and updated section headings for regulations. Formatting and typographical errors were corrected throughout the LCD.

  • Provider Education/Guidance
06/23/2022 R22

Under CMS National Coverage Policy updated section headings for regulations. The following regulations were removed and placed in the related Billing and Coding: Home Health Physical Therapy A53058 article: CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 32, §11.2 and CMS Internet-Only Manual, Pub. 100-08, Medicare Program Integrity Manual, Chapter 6, §6.2.4. The following regulations were removed: CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Transmittal 179, dated January 14, 2014, Change Request 8458 and Program Memorandum, Transmittal AB-02-078, dated May 29, 2002, Change Request 2083 Medicare Coverage of Rehabilitation Services for Beneficiaries With Vision Impairment. Under Associated Information subheading Documentation Requirements removed the following verbiage regarding functional reporting requirements:

"Functional reporting uses non-payable G-codes and related modifiers to convey information about the patient’s functional status at specified points during treatment. This functional data reporting is effective for therapy services with dates of service on and after January 1, 2013. The functional reporting requirements apply to the therapy services furnished by the following providers: CAHs, SNFs, CORFs, rehabilitation agencies, and HHAs (where a beneficiary is not under a home health plan of care).

In the medical record, functional documentation must be included:

  • at the beginning of a therapy episode of care
  • in the therapy POC as functional limitations and expressed as part of the patient’s long term goals
  • as the patient’s current status, projected goal, and discharge status (for each date of service)
  • in the progress report at the end of each progress reporting period, i.e. at least once every tenth treatment day
  • at the time of discharge, on the discharge note or summary
  • when an evaluation or re-evaluation is furnished and billed
  • for reporting that a particular functional limitation is ended, but further therapy is required
  • when reporting is begun for a new or different functional limitation during the same therapy episode

Documentation of functional reporting in the medical record of therapy services must be completed by the clinician furnishing the therapy services:

  • The qualified therapist furnishing the therapy services
  • The physician/NPP personally furnishing the therapy services
  • The qualified therapist furnishing services incident to the physician/NPP
  • The physician/NPP for incident to services furnished by qualified personnel, who are not qualified therapists.
  • The qualified therapist furnishing the PT, OT, or SLP services in a CORF”

Under Bibliography changes were made to citations to reflect AMA citation guidelines. Acronyms were defined and inserted where appropriate throughout the LCD. Formatting, punctuation and typographical errors were corrected throughout the LCD.

  • Provider Education/Guidance
10/24/2019 R21

This LCD is being revised in order to adhere to CMS requirements per Chapter 13, Section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs. There has been no change in coverage with this LCD revision. Regulations regarding billing and coding were removed from the CMS National Coverage Policy section of this LCD and placed in the related Billing and Coding: Home Health Physical Therapy A53058 article.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Provider Education/Guidance
08/15/2019 R20

All coding located in the Coding Information section has been moved into the related Billing and Coding: Home Health Physical Therapy A53058 article and removed from the LCD.

All verbiage regarding billing and coding under the Coverage Indications, Limitations and/or Medical Necessity section has been removed and is included in the related Billing and Coding: Home Health Physical Therapy A53058 article. Formatting, punctuation and typographical errors were corrected throughout the LCD.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Provider Education/Guidance
04/22/2019 R19

This revision is to remove contract number 11401 which was inadvertently added to Revision 18.

  • Provider Education/Guidance
04/22/2019 R18

Under Coverage Indications, Limitations and/or Medical Necessity removed the first paragraph regarding quoted Internet Only Manual (IOM) text and removed quoted IOM text from the third paragraph. Under subheading Maintenance Therapy removed quoted IOM text and changed verbiage to read ”Coverage of skilled rehabilitation services is contingent upon beneficiary’s need for skilled care whether the goals of therapy include maintenance or improvement”. Under subheading Restorative/Rehabilitative Therapy removed quoted IOM text and changed verbiage to read “Restorative/rehabilitative therapy has the purpose of improving function or reversing loss of function”. Under subheading General Physical Therapy Guidelines removed quoted IOM text and changed verbiage to read “A beneficiary must require the services of a skilled physical therapist for the service to be covered. The pressing need for a service, or the lack of availability of unskilled personnel to render the service with the necessary frequency does not itself make a service skilled. However, some services that would not normally be considered skilled therapy, may require the skilled services of a therapy professional care because of a special complicating medical factor. This must be clearly evident in the medical record. Rehabilitation Services for Vision Impairment- Partial or complete vision loss may make therapy to improve activities of daily living reasonable and necessary”. Under subheading PT Evaluation and PT Re-evaluation removed quoted IOM text and changed verbiage to read “Evaluation is warranted at the start of therapy or when the beneficiary’s condition changes or treatment needs change so as to potentially warrant a new plan of care or a change to an existing plan of care”. Under #4. removed quoted IOM text and changed verbiage to read “Re-evaluation is considered reasonable and necessary when the beneficiary’s condition changes or treatment needs change so as to potentially warrant a new plan of care or a change to an existing plan of care”. Under #5. removed quoted IOM text. Under subheading Maintenance Programs removed quoted IOM text and changed verbiage to read “A maintenance program is a program designed to help a beneficiary maintain an existing level of function or minimize a loss of function. Coverage of skilled rehabilitation services is contingent upon beneficiary’s need for skilled care whether the goals of therapy include maintenance or improvement.” Under subheading Paraffin Bath #2. removed quoted IOM text and changed verbiage to read “Heat treatments alone do not typically make the skills of a therapist reasonable and necessary. However, heat treatments in the presence of a complicating medical factor may make the skills of a therapist reasonable and necessary.” Under subheading Gait Training Therapy removed quoted IOM text. Under subheading Self-Care/Home Management Training removed quoted IOM text. Under Associated Information: Documentation Requirements #5. removed quoted IOM text and changed verbiage to read “The home health clinical notes must contain documentation elements as outlined in CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7, §40.2.1”. Under #7. IOM text was removed. Under #8. removed quoted IOM text and changed verbiage to read “In maintenance programs the documentation must reflect that skilled therapy is necessary to achieve the goals of the planned maintenance program.” Under #9. removed quoted IOM text and changed verbiage to readPhysician documentation must support coverage.” Under #10. removed quoted IOM text and changed verbiage to readUnder a restorative program the therapist should adjust the exercise program when needed to meet the beneficiary's needs in response to regular re-evaluation.” Under subheading Evaluation/Re-Evaluations removed quoted IOM text and changed verbiage to read “Evaluations must contain the referral reason, conditions treated with therapy, and prior level of function, current level of function, and exam findings, Objective measurements must be used to support this information. In addition, planned treatment techniques, limitations, goals, and planned frequency and duration of therapy must also be documented”. Under subheading Plan of Treatment removed quoted IOM text and changed verbiage to read “Services must be delivered in accordance with a plan of care, which contains the following: Diagnosis and problems being addressed planned treatment techniques, measurable functional goals, frequency and duration of service, and rehabilitation potential”. Under subheading Treatment Note/Clinical Notes/Progress Notes removed quoted IOM text and changed verbiage to read “A treatment note should be written for each visit describing the services performed as well as the patient’s progress, and any treatment variations from the plan of care with an explanation for them. Progress must be documented using specific and objective descriptions (e.g., range of motion in degrees, distance that can be walked, validated scales of functional independence). Vague descriptions such as “doing well” or “continue treatment plan,” will not be considered sufficient documentation of the treatment session to justify that the services rendered were reasonable and necessary.” Under subheading Certification/Re-certification removed quoted IOM text and changed verbiage to read “Certification requirements must be met as per CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7, §30.5”. Under subheading Utilization Guidelines removed quoted IOM text and changed verbiage to readThe record must indicate whether the plan is restorative or for maintenance.” Formatting, punctuation and typographical errors were corrected throughout the LCD. Acronyms were inserted and defined where appropriate throughout the LCD. CPT® was inserted throughout the LCD where applicable.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Provider Education/Guidance
10/01/2018 R17

Under ICD-10 Codes That Support Medical Necessity deleted ICD-10 codes M79.1, T81.4XXD and T81.4XXS. The code description was revised for ICD-10 codes L98.495, L98.496, L98.498, S62.626D, S62.626G, S62.626K, S62.626P, S62.626S, S62.627D, S62.627G, S62.627K, S62.627P, S62.627S, S62.654D, S62.654G, S62.654K, S62.654P, S62.654S, S62.655D, S62.655G, S62.655K, S62.655P, S62.655S, S62.656D, S62.656G, S62.656K, S62.656P, S62.656S, S62.657D, S62.657G, S62.657K, S62.657P and S62.657S. This revision is due to the Annual ICD-10 Code Update and becomes effective October 1, 2018.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Revisions Due To ICD-10-CM Code Changes
03/08/2018 R16

Under Coverage Indications, Limitations and/or Medical Necessity deleted the second, third and fourth sentence in the first paragraph. Under Electrical Stimulation Therapy (CPT code 97032) removed the existing verbiage and replaced with “Electrical Nerve Stimulation (TENS) is not reasonable and necessary for the treatment of Chronic Low Back Pain (CLBP) under §1862 (a)(1)(A) of the Act”.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

 

  • Provider Education/Guidance
01/01/2018 R15

Under CMS National Coverage Policy added CMS Manual System, Pub 100-04, Medicare Claims Processing Manual, Change Request 10308, Transmittal 3877, dated October 6, 2017. Under Coverage Indications, Limitations and/or Medical Necessity – Prosthetic Checkout deleted CPT code 97762 and replaced with CPT code 97763. Under CPT/HCPCS Codes Group 2 descriptions were revised for CPT codes 97760 and 97761. This revision is due to the Annual CPT/HCPCS Code Update.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

 

  • Revisions Due To CPT/HCPCS Code Changes
10/01/2017 R14

Under ICD-10 Codes That Support Medical Necessity Group 1: Codes deleted ICD-10 codes M48.06, S63.131A, S63.131D, S63.131S, S63.132A, S63.132D, S63.132S, S63.134A, S63.134D, S63.134S, S63.135A, S63.135D, S63.135S, S63.141A, S63.141D, S63.141S, S63.142A, S63.142D, S63.142S, S63.144A, S63.144D, S63.144S, S63.145A, S63.145D and S63.145S. Under ICD-10 Codes That Support Medical Necessity Group 1: Codes added ICD-10 codes G12.23, G12.24, G12.25, L97.115, L97.116, L97.118, L97.125, L97.126, L97.128, L97.215, L97.216, L97.218, L97.225, L97.226, L97.228, L97.315, L97.316, L97.318, L97.325, L97.326, L97.328, L97.415, L97.416, L97.418, L97.425, L97.426, L97.428, L97.515, L97.516, L97.518, L97.525, L97.526, L97.528, L97.815, L97.816, L97.818, L97.825, L97.826, L97.828, L97.915, L97.916, L97.918, L97.925, L97.926, L97.928, L98.415, L98.416, L98.418, L98.425, L98.426, L98.428, L98.495, L98.496, L98.498, M48.061 and M48.062. Under ICD-10 Codes That Support Medical Necessity Group 1: Codes code description changes were made to ICD-10 codes I83.811, I83.812, I83.891, I83.892, S62.311D, S62.311G, S62.311K, S62.311P, S62.311S, S62.317D, S62.317G, S62.317K, S62.317P, S62.317S, S62.341D, S62.341G, S62.341K, S62.341P, S62.341S, S62.347D, S62.347G, S62.347K, S62.347P, S62.347S, S62.620D, S62.620G, S62.620K, S62.620P, S62.620S, S62.621D, S62.621G, S62.621K, S62.621P, S62.621S, S62.622D, S62.622G, S62.622K, S62.622P, S62.622S, S62.623D, S62.623G, S62.623K, S62.623P, S62.623S, S62.624D, S62.624G, S62.624K, S62.624P, S62.624S, S62.625D, S62.625G, S62.625K, S62.625P, S62.625S, S62.650D, S62.650G, S62.650K, S62.650P, S62.650S, S62.651D, S62.651G, S62.651K, S62.651P, S62.651S, S62.652D, S62.652G, S62.652K, S62.652P, S62.652S, S62.653D, S62.653G, S62.653K, S62.653P, S62.653S, S63.121A, S63.121D, S63.121S, S63.122A, S63.122D, S63.122S, S63.124A, S63.124D, S63.124S, S63.125A, S63.125D, S63.125S, S92.521A, S92.521B, S92.521D, S92.521G, S92.521K, S92.521P, S92.521S, S92.522A, S92.522B, S92.522D, S92.522G, S92.522K, S92.522P, S92.522S, S92.524A, S92.524B, S92.524D, S92.524G, S92.524K, S92.524P, S92.524S, S92.525A, S92.525B, S92.525D, S92.525G, S92.525K, S92.525P and S92.525S. This revision is due to the 2017 Annual ICD-10 Code Updates.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.



 

 

  • Revisions Due To ICD-10-CM Code Changes
03/16/2017 R13 Under CMS National Coverage Policy for title 42 CFR §409.42 added the verbiage “Beneficiary qualifications for coverage of services”, for 42 CFR §409.43 added the verbiage “Plan of care requirements”, for 42 CFR §409.44 added the verbiage “Skilled services requirements”, for 42 CFR §410.61 added the verbiage “Plan of treatment requirements for outpatient rehabilitation services” and 42 CFR §424.22 added the verbiage “Requirements for Home Health Services”. Under Sources of Information and Basis for Decision added the supplement number “2” to the Matsumura BA, Ambrose AF. Balance in the Elderly. Clin in Geriat Med. 2006;22(2):395-412.
  • Provider Education/Guidance
  • Typographical Error
01/01/2017 R12 Under CMS National Coverage Policy added Change Request 9771, Transmittal 3618. Under Coverage Indications, Limitations and/or Medical Necessity revised the short description “PT Evaluation (CPT code 97001) and PT Re-evaluation (CPT code 97002)” to now read “PT Evaluation (CPT code 97161, 97162 and 97163) and PT Re-evaluation (CPT code 97164)”. Under CPT/HCPCS Codes Group 2 deleted CPT Codes 97001 and 97002 and added CPT Codes 97161, 97162, 97163 and 97164. This revision is due to the 2017 Annual CPT/HCPCS Update and becomes effective 01/01/17.
  • Provider Education/Guidance
  • Revisions Due To CPT/HCPCS Code Changes
  • Other (Change Request 9771, Transmittal 3618.)
10/13/2016 R11 Under Associated Information-Documentation Requirements -Evaluation/Reevaluations #9 deleted the verbiage “…and their expected date of accomplishment” and revised this statement to now read “Short and/or long term goals stated in objective measurable terms”.
  • Provider Education/Guidance
  • Other
10/01/2016 R10 Under ICD-10 Codes That Support Medical Necessity added ICD-10 codes G56.03, G56.13, G56.23, G56.33, G56.43, G56.83, G56.93, G57.03, G57.13, G57.23, G57.33, G57.43, G57.53, G57.63, G57.73, G57.83, G57.93, G61.82, I69.010, I69.011, I69.012, I69.013, I69.014, I69.015, I69.018, I69.019, I69.110, I69.111, I69.112, I69.113, I69.114, I69.115, I69.118, I69.119, I69.210, I69.211, I69.212, I69.213, I69.214, I69.215, I69.218, I69.219, I69.310, I69.311, I69.312, I69.313, I69.314, I69.315, I69.318, I69.319, I69.810, I69.811, I69.812, I69.813, I69.814, I69.815, I69.818, I69.910, I69.911, I69.912, I69.913, I69.914, I69.915, I69.918, M25.541, M25.542, M50.020, M50.021, M50.022, M50.023, M50.121, M50.122, M50.123, M84.750S, M84.751S, M84.752S, M84.754S, M84.755S, M84.757S, M84.758S, M97.01XD, M97.01XS, M97.02XD, M97.02XS, M97.11XD, M97.11XS, M97.12XD, M97.12XS, M97.21XD, M97.21XS, M97.22XD, M97.22XS, M97.31XD, M97.31XS, M97.32XD, M97.32XS, M97.41XD, M97.41XS, M97.42XD, M97.42XS, S03.01XD, S03.01XS, S03.02XD, S03.02XS, S03.03XD, S03.03XS, S92.811D, S92.811S, S92.812D, S92.812S, S99.001D, S99.001S, S99.002D, S99.002S, S99.011D, S99.011S, S99.012D, S99.012S, S99.021D, S99.021S, S99.022D, S99.022S, S99.031D, S99.031S, S99.032D, S99.032S, S99.041D, S99.041S, S99.042D, S99.042S, S99.091D, S99.091S, S99.092D, S99.092S, S99.101D, S99.101S, S99.102D, S99.102S, S99.111D, S99.111S, S99.112D, S99.112S, S99.121D, S99.121S, S99.122D, S99.122S, S99.131D, S99.131S, S99.132D, S99.132S, S99.141D, S99.141S, S99.142D, S99.142S, S99.191D, S99.191S, S99.192D, S99.192S, S99.201D, S99.201S, S99.202D, S99.202S, S99.211D, S99.211S, S99.212D, S99.212S, S99.221D, S99.221S, S99.222D, S99.222S, S99.231D, S99.231S, S99.232D, S99.232S, S99.241D, S99.241S, S99.242D, S99.242S, S99.291D, S99.291S, S99.292D, S99.292S, T82.855D, T82.855S, T82.856D and T82.856S, deleted ICD-10 codes M50.12, M50.22, S02.10XD, S02.10XG, S02.10XK, S02.10XS, S02.3XXD, S02.3XXG, S02.3XXK, S02.3XXS, S02.61XD, S02.61XG, S02.61XK, S02.61XS, S02.62XD, S02.62XG, S02.62XK, S02.62XS, S02.63XD, S02.63XG, S02.63XK, S02.63XS, S02.64XD, S02.64XG, S02.64XK, S02.64XS, S02.65XD, S02.65XG, S02.65XK, S02.65XS, S02.67XD, S02.67XG, S02.67XK, S02.67XS, S02.8XXD, S02.8XXG, S02.8XXK, S02.8XXS, S03.0XXA, S03.0XXD, S03.0XXS, S03.4XXA, S03.4XXD, S03.4XXS, T83.51XS, T83.59XS, T83.6XXS, T84.040D, T84.040S, T84.041D, T84.041S, T84.042D, T84.042S, T84.043D, T84.043S, T84.048D, T84.048S, T85.81XD, T85.81XS, T85.82XD, T85.82XS, T85.83XD, T85.83XS, T85.84XD, T85.84XS, T85.85XD, T85.85XS, T85.86XD, T85.86XS, T85.89XD and T85.89XS and revised the code descriptions for ICD-10 codes S02.110D, S02.110G, S02.110K, S02.110S, S02.111D, S02.111G, S02.111K, S02.111S, S02.112D, S02.112G, S02.112K, S02.112S, S02.118D, S02.118G, S02.118K, S02.118S, S02.400D, S02.400G, S02.400K, S02.400S, S02.401D, S02.401G, S02.401K, S02.401S, S02.402D, S02.402G, S02.402K, S02.402S, S02.600D, S02.600G, S02.600K, S02.600S, S49.031A, S49.031D, S49.031G, S49.031K, S49.031P, S49.031S, S49.032A, S49.032D, S49.032G, S49.032K, S49.032P, S49.032S, S49.131A, S49.131D, S49.131G, S49.131K, S49.131P, S49.131S, S49.132A, S49.132D, S49.132G, S49.132K, S49.132P, S49.132S, S54.8X1A, S54.8X1D, S54.8X1S, S54.8X2A, S54.8X2D, S54.8X2S, T82.817D, T82.817S, T82.818D, T82.818S, T82.827D, T82.827S, T82.828D, T82.828S, T82.837D, T82.837S, T82.838D, T82.838S, T82.847D, T82.847S, T82.848D, T82.848S, T82.857D, T82.857S, T82.858D, T82.858S, T82.867D, T82.867S, T82.868D, T82.868S, T83.711S, T83.718S, T83.721S, T83.728S, T83.81XS, T83.82XS, T83.83XS, T83.84XS, T83.85XS, T83.86XS, T85.110D, T85.110S, T85.111D, T85.111S, T85.112D, T85.112S, T85.120D, T85.120S, T85.121D, T85.121S, T85.122D, T85.122S, T85.190D, T85.190S, T85.191D, T85.191S, T85.192D, T85.192S, T85.610D, T85.610S, T85.690D, and T85.690S. This revision is due to the Annual ICD-10 Code Update and becomes effective 10/01/16.
  • Provider Education/Guidance
  • Revisions Due To ICD-10-CM Code Changes
08/04/2016 R9 Under ICD-10 Codes that Support Medical Necessity added G80.0, G80.1, G80.2, G80.4, G80.8 and G80.9.
  • Provider Education/Guidance
  • Creation of Uniform LCDs Within a MAC Jurisdiction
06/23/2016 R8 Throughout the entire LCD added “Manual” to multiple citations. Under Associated Information-Documentation Requirements-Evaluation/Reevaluations 9. revised the statement to now read, “Short and/or long term goals stated in objective measurable terms, and their expected date of accomplishment.” This revision recognizes that while best practices support the communication of both short and long term goals for rehabilitation services, either may support the reasonable and necessary home health services described in this LCD.
  • Provider Education/Guidance
  • Other
03/10/2016 R7 Under CMS National Coverage Policy corrected punctuation, corrected the title and date cited for Transmittal AB-02-078, Change Request 2083, and deleted the information cited for Transmittal 603, Change Request 9189 as this information has been manualized. Under Coverage Indications, Limitations and/or Medical Necessity throughout the section text was italicized as the language was quoted from the Centers for Medicare and Medicaid Services (CMS) National Coverage Determinations (NCDs) or coverage provisions in interpretive manuals. Under Coverage Indications, Limitations and/or Medical Necessity in the third paragraph deleted the verbiage “…as discussed below.” Under Maintenance Programs deleted the last paragraph as it was redundant. Under Hot or Cold Packs Therapy deleted the statement related to heat treatments and baths as this was redundant and renumbered statement #3 to now read statement #2. Under Diathermy Treatment (CPT code 97024) and Infrared Therapy (CPT code 97026) added “s” to Determination and added Manual. Under Contrast Bath Therapy (CPT code 97034) #4 revised “whirlpool” to now read “contrast”. Under CPT/HCPCS Codes Group 1: Codes added G0157 and G0159 and deleted the first sentence, “As of Jul 1999…” as this is redundant. Under CPT/HCPCS Codes Group 2: Codes deleted G0157 and G0159. Under Associated Information-Documentation Requirements 1. deleted “the”. Under Sources of Information and Basis for Decision added author names and initials, corrected the page number for American Medical Association. CPT Assistant, July 2004 and added 4th Ed. to Studenski S, Duncan P, Maino J. Principles of Rehabilitation in Older Patients. In: Hazzard WR, Blass JP, Ettinger WH, et al (eds). Principles of Geriatric Medicine and Gerontology.
  • Provider Education/Guidance
  • Other
02/04/2016 R6 Under CPT/HCPCS Codes Group 2 added G0157 and G0159 for reference to PT Assistant and PT Maintenance.
Under ICD-10 Codes that Support Medical Necessity added numerous 7th digits to ICD-10 codes for additional coverage of Physical Therapy services.
  • Provider Education/Guidance
  • Public Education/Guidance
  • Request for Coverage by a Provider (Part A)
  • Other (Reconsideration for Outpatient PT L34428 to add additional coverage. Added the same codes to HH PT for consistency. )
10/01/2015 R5 Under CMS National Coverage Policy added the following: 42 CFR §409.42-Beneficiary qualifications for coverage of services, Title XVIII of the Social Security Act, §1835 (a)(2)(A) Procedure for payment of claims of providers of services, Title XVIII of the Social Security Act, §1814 (a)(2)(C) Requirements of requests and certifications and CMS Internet-Only Manual, Pub 100-08, Medicare Program Integrity Manual, Transmittal 603, dated July 21, 2015, Change Request 9189.
Under Coverage Indications, Limitations and /or Medical Necessity made a few punctuation and spacing corrections.
Under Associated Information-Documentation Requirements #2. Added the word “dated” to plan of treatment requirements; made a few punctuation and spacing revisions, in Certification/Re-Certification added “In order for Home Health patients to be eligible to receive services under the Medicare Home Health benefit the following must be documented for certification/recertification:”, moved #3 to the end of #4 and added the following clarification to #4 “If the requirements for certification are not met then claims for subsequent episodes of care, which require a recertification, will not be covered- even if the requirements for recertification’s are met”, added under #3 “Patient is under a physician care”, changed #5 to read “Skilled need- services must be medically necessary and documentation of the skilled need should be in the patients medical record”, #6 was created and is the previous wording for #5, and #7 created to read “patient must be homebound”. Under Utilization Guidelines removed “on the CMS 485 or on the OASIS M1800-M1910”.

Bill Type Code 033X was removed per CR8244 with the May Bill Type/Revenue Code update.
  • Provider Education/Guidance
  • Other (change request 9189, Transmittal 603.)
10/01/2015 R4 A description change was made to Bill Type codes per the NUBC Quarterly update in May 2015.
  • Provider Education/Guidance
10/01/2015 R3 Under CMS National Coverage Policy added reference to Pub 100-02, Chapter 7 section 30.5.1.1 regarding Face-To-Face requirements; added reference to Pub 100-02, Chapter 15, Sections 220, 220.2, 230, 230.1 and 230.5; added reference to CR 8458; added reference to Pub 100-04, Chapter 5, Section 10.6; added reference to Pub 100-03, Chapter 1, part 4, Section 240.3 and removed 280.13; added reference to 42 CFR sections 409.43, 409.44, 410.61 and 424.22. Under Coverage Indications, Limitations and /or Medical Necessity made several grammatical and punctuation changes, added statement from CR 2083 regarding Vision Impairment "A Medicare beneficiary with vision loss may be eligible for rehabilitation services designed to improve functioning, by therapy, to improve performance of activities of daily living, including self-care and home management skills. Evaluation of the patient’s level of functioning in activities of daily living, followed by implementation of a therapeutic plan of care aimed at safe and independent living, is critical and should be performed by an occupational or physical therapist", removed the sentence "the coverage criteria and definition of rehabilitative services for vision impairment (Low Vision) is found in transmittal AB-02-078, dated May 28, 2002, Change Request 2083" as it is now in the policy, corrected the spelling of Velpeau for CPT code 29240, under General Guidelines for Therapeutic Procedures added "qualified" to physical therapist, added Sensory Integrative Techniques (CPT code 97533) "Sensory integrative techniques are interventions generally intended for the pediatric and/or neurologically impaired populations. The focus of these activities is to train the sensory systems to modulate the vast array of incoming sensory stimuli. This is something that is normally performed without apparent effort. Once the patient/client learns to block the extrasensory 'noise,' the important sensory input can be processed and a coordinated motor response can be generated", Under Wheelchair Management Training added "qualified" physical therapist; added Assistive Technology Assessment (CPT code 97755) This assessment requires professional skill to gather data by observation and patient inquiry and may include limited objective testing and measurement to make clinical judgments regarding the patient's condition(s). Assessment determines, e.g., changes in the patients status since the last visit and whether the planned procedure or service should be modified. Based on these assessment data, the professional may make judgment about progress toward goals and/or determine that a more complete evaluation or reevaluation is indicated.
Under Bill Type Codes removed 033x per Change Request 8244.
Under Group 2 CPT/HCPCS Codes added 97533.
Under Associated Information added entire section on Functional Reporting and reworded the Utilization Guidelines to read Whether the plan is rehabilitative/restorative or maintenance should be indicated on the CMS-485 or on the OASIS M1800-M1910 with current rerence to ADL/IADL's and current ability.
Under Sources of Information and Basis for Decision corrected all sources to AMA formatting, added references for CPT assistant x 5, coding consultation, ICF manual, A Payer's Guide, and Balance in the Elderly.
  • Provider Education/Guidance
10/01/2015 R2 Under Coverage Indications, Limitations and/or Medical Necessity, General Physical Therapy Guidelines:
removed "A service that is ordinarily considered unskilled could be considered a skilled therapy service in cases where there is clear documentation that, because of special medical complications, skilled rehabilitation personnel are required to perform the service. However, the importance of a particular service to a patient or the frequency with which it must be performed does not, by itself, make an unskilled service into a skilled service"
and in Maintenance Programs: removed 5. Where services that are required to maintain the patient’s current function or to prevent or slow further deterioration are of such complexity and sophistication that the skills of a qualified therapist are required to perform the procedure safely and effectively, the services would be covered physical therapy services. Further, where the particular patient’s special medical complications require the skills of a qualified therapist to perform a therapy service safely and effectively that would otherwise be considered unskilled, such services would be covered physical therapy services. as these were duplicate statements.
  • Typographical Error
10/01/2015 R1 Under ICD-10 Codes That Support Medical Necessity-Group 1 ICD-10 Codes effective 06/29/2014, ICD-10 code description verbiage was revised due to the 2014 & 2015 Annual ICD-10 Code Update for the following: M08.88, M12.08, M50.11, M50.21, M84.58XS.
  • Provider Education/Guidance
  • Revisions Due To ICD-10-CM Code Changes
N/A

Keywords

  • Physical Therapy
  • PT

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